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Clavicular Fractures & AC Joint Injuries
Above the rotator cuff is a bony mass that sits on the shoulder blade, or scapula, called the acromion. This constitutes the top of the shoulder. The acromion is the headquarters for the deltoid muscle and connects to the collarbone, or clavicle, to form the AC joint, or Acromioclavicular joint. Problems often occur to this joint as a result of a fall or impact to the outside part of the shoulder. Often called an AC separation, these injuries are seen most often in contact sports and in biking and skiing falls.
When an AC separation occurs, patients will complain of pain and the presence of a bump on the top of the shoulder. The bump really is not new, but rather the end of the collarbone, which used to be connected to the acromion. Gravity causes the acromion and the rest of the arm to sag, which causes the end of the collarbone to appear larger.
Most of these problems can be treated without surgery. Dr. Sanders utilizes a Cryo/Cuff® to keep the area cold and compressed. This relieves pain and swelling. Advil or Tylenol is also effective for pain relief. After a very short period of rest, the same range of motion exercises used for Rotator Cuff injuries are employed to complete the rehabilitation and patients are back at their sport in two weeks.
In the rare case of a marked displacement and severe weakness of the deltoid muscle, an outpatient surgical repair is performed to restore the ligaments maintaining the Acromioclavicular region. Dr. Sanders employees a simple, time tested, and effective procedure which carries with it a very high success rate. After an arthroscopic exam rules out other treatable causes of shoulder pain, the distal few millimeters of the clavicle are removed because the severity of injury to the articular cartilage will certainly leave this joint arthritic. Heavy Number 5 Fiber Wire® sutures are passed underneath the coracoid, and taken through the clavicle through two 2 millimeter drill holes and tied over a simple, inexpensive 15 mm ligament button, slightly smaller than the one we use for ACL surgery. Following surgery, a Cryo/Cuff® is placed around the area, and immediate range of motion exercises begun. Most patients will be back in competition by three months’ time.
In several hundred cases we have encountered less than 5% complications with this procedure. They have been limited to tobacco (of any type) abusers who don’t heal well, and those patients who are extremely thin, and can feel the button. Several of them have requested that the button be removed after the repair is solid.
The medical equipment industry, the young and impressionable Orthopaedic surgeons, and their internet savvy patients tend quickly embrace new “cutting edge” things, and newer procedures have been introduced in which ligament grafts or a Tight Rope® is passed between the coracoid and clavicle. Well, in this circumstance, the “cutting edge” is also the “bleeding edge”. The clavicle is about 12 mm wide from front to back. Passing an 8 mm graft and its ever present plastic screw, through the 8 mm drill hole in the clavicle leaves only 2 mm of intact clavicle on either side. Small wonder the serious complication rate, made up mostly of post-operative clavicle fractures approaches 18-20%! And these fractures with only 2 millimeters of bone on each side are almost unreconstructable. These problems lead to far worse results than the untreated AC separation! Dr. Sanders has found that the Tight Rope® procedure doesn’t anchor the sutures as well in the coracoid process, and it is subject to tearing out, or a development of a stiff shoulder, as the surgeon must be very careful to avoid it from tearing out in the early period. For this reason, accelerated rehabilitation is not possible. In these settings, Dr. Sanders keeps things “real” avoids the “kooky and spooky” and sticks with the things have worked well for decades.
In many cases, arthritic degeneration of the Acromioclavicular joint can occur even without history of a ligament injury. This is often seen in weightlifters. Treatment is basically the same as for AC arthritis, with non-surgical methods preferred. Simple arthroscopic shoulder surgery may be necessary in recalcitrant cases.
Not infrequently AC arthritis is coexistent with disorders of the rotator cuff. When this happens, treatments are directed to the rotator cuff problem. However, in those rotator cuff cases requiring surgery, surgical attention is also directed to the removal of the spurs - which exist on the terminal five millimeters of the clavicle and the most medial aspects of the acromion. Rehabilitation in these cases is directed by the presence of a newly repaired rotator cuff.
Fractures of the clavicle or collarbone are common injuries in sports, and among the most common injuries in cycling and off road motorcycling. Most off road motorcyclists will break either one or both during their career. This injury is no longer considered a minor one and displaced fractures that heal crooked will, in many cases, cause permanent problems such as pain, weakness, and deformity.
For nondisplaced fractures, the first five to seven days should be spent in a simple sling. Dr. Sanders does not advocate a Figure of Eight bandage for a fractured clavicle, as it does little to improve the position of the fractured bones. Nor does it relieve pain.
After a week to ten days, athletes may begin moving their shoulder - working on trying to lift it over their head and improve range of motion. Follow up X-rays must be taken in adults to assure that the minimally displaced fracture fragments do not migrate. After six weeks, or when the clicking or popping sounds subside, patients may begin lifting lightweight objects - such as an unopened soda can - to build strength. Heavier weight can be added as comfort allows. Younger patients are back at their sport by eight weeks, while older patients require more time - usually three months.
In both adolescents and adults, severe displacement, characterized by overriding of the fragments, fracture fragments threatening to pierce the skin, multiple fractures in the extremity, associated nerve injury, multiple rib fractures, or fractures close to the shoulder end of the clavicle - surgical treatment is necessary. While these high-energy fractures are not common in most sports, a great number of fractures incurred by off road motocross and mountain bike riders are of this type. In these more severe cases, surgical treatment is performed with a pre-contoured plate and screws placed on the front of the bone. Occasionally, bone graft is added to maximize the chances of early healing and speedy return to sports. Since the newer plates are low profile and may be placed in a locking mode, stress shielding of the bone is less likely and hardware removal is generally not necessary, except in very thin patients who can sometimes be annoyed that they can feel the plate.
This procedure may be performed on an outpatient basis and will allow for early motion of the shoulder and upper extremity. It typically will result in bony healing before three months and a timely return to sports, particularly off road motorcycling.
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Houston Orthopedic and Sports Medicine Physician Mark Sanders, M.D., Joins American Orthopaedic Foot and Ankle Society
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